Midazolam Facts

“Potassium chloride feels like liquid fire as it courses through the veins…It is constitutionally intolerable to use these drugs to execute any prisoner still capable of sensing pain…The Framers placed off limits such means of execution as burning a prisoner. From the perspective of causing intolerable pain and suffering, injecting a prisoner with liquid fire is just as unconstitutional as lighting him afire.”

What is Midazolam?

– Midazolam, commonly known under the trade name Versed, is the shortest-acting drug in the benzodiazepine class.

– Benzodiazepines are a class of drugs primarily used for treating anxiety. They include drugs such as Valium, Ativan, and Xanax.

– Clinically, midazolam is typically administered to treat anxiety and lightly sedate a patient prior to the induction of anesthesia in a surgical setting.

What Midazolam Can’t Do

– Midazolam is not FDA-approved as the sole drug to produce and maintain anesthesia during painful surgical procedures.

– Midazolam has no analgesic or pain-relieving properties. All of the experts who testified during the three-day hearing in Federal District Court that midazolam has no analgesic or pain-relieving properties.

– Midazolam, when administered without additional pain-relieving drugs, does not render a person insensate to noxious or painful stimuli. In Baze v. Rees, the United States Supreme Court acknowledged that administering the second and third drugs to a prisoner who is not deeply anesthetized would be unconstitutional. The pharmacological properties of midazolam make the drug unable to produce the “deep, comalike unconsciousness” required by the Court in Baze.

– David Lubarsky, M.D., a board-certified anesthesiologist and Professor of Anesthesiology testified that, “[M]idazolam cannot produce the depth of anesthesia and unconsciousness that is necessary to reliably render the condemned insensate to the following effects of vecuronium bromide and suffocation and potassium chloride and the burning.”

Midazolam’s Ceiling Effect

– Administering a larger dose of midazolam will not increase the effects so that midazolam will produce the necessary level of unconsciousness. Midazolam, like all benzodiazepines, exhibits a “ceiling effect,” meaning that increasing the dose will not have an increased effect. After the botched execution of Charles Lockett, Oklahoma increased the dose of midazolam from 100mg to 500mg; however, Larry Sasich, Pharm. D, stated in his stated in his report that “[he] could find no evidence to suggest that a 500 mg dose of midazolam rather than 100 mg would have prevented the events Mr. Lockett suffered” (p. 7 of Dr. Sasich’s report, located on p. 91 of Appendix Volume II of the Petition for a Writ of Certiorari).

– In Arizona, Joseph Wood was administered fourteen times the dose of midazolam and hydromorphone required in the protocol. In the nearly two-hour execution during media witnesses observed him “snorting and gasping for air.”

– Because of midazolam’s ceiling effect, “[T]he studies show that although midazolam can induce unconsciousness and unresponsiveness to minor stimuli, a person rendered unconscious by midazolam is not in a coma-like state and can be ‘jolted into consciousness’ by the infliction of pain.” (p. 13) (For more details on how midazolam works on the brain, see pp 14 – 17 of the Petitioner’s brief)

Which States Use Midazolam in Executions?

– Midazolam has been used to carry out executions as part of a two or three-drug protocol in Arizona, Florida, Ohio and Oklahoma.

– It was first used by Florida in the execution of William Happ on October 15, 2013. Media witnesses reported, “It appeared Happ remained conscious longer and made more body movements after losing consciousness than other people executed recently by lethal injection under the old [drug] formula.”

– Midazolam has been involved in several extremely problematic executions, including the prolonged executions of Dennis McGuire in Ohio and Joseph Wood in Arizona, as well as the botched exaction of Clayton Lockett in Oklahoma.

Paradoxical Reactions

– The administration of midazolam can also cause paradoxical reactions where the drug does not work as intended. In these instances, instead of relieving anxiety or resulting in sedation, the administration of midazolam can cause induced anxiety, discoordinated movement, hyperactivity and/or aggression.

– Vulnerable populations, such the elderly, people with a history of aggression, impulsivity, alcohol abuse and other psychiatric disorders, are at higher risk for paradoxical reactions.

Masking Midazolam’s Effect in Executions

– The state of Oklahoma argues that Florida has carried out numerous three-drug executions using midazolam without incident and the Oklahoma execution of Charles Warner on January 15, 2015 went according to plan. However, both states require a chemical paralytic as part of the process, which will mask any signs of consciousness or pain once administered. In her dissent, Justice Sonia Sotomayor wrote, “[Florida’s] apparent success with that method is subject to question because the injection of the paralytic vecuronium bromide may mask the ineffectiveness of midazolam as an anesthetic: The inmate may be fully conscious but unable to move.”

Question Presented

Is it constitutionally permissible for a state to carry out an execution using a three-drug protocol where: (a) there is a well-established scientific consensus that the first drug has no pain relieving properties and cannot reliably produce deep, comalike unconsciousness, and (b) it is undisputed that there is a substantial, constitutionally unacceptable risk of pain and suffering from the administration of the second and third drugs when a prisoner is conscious?

“Oklahoma’s selection of midazolam was grounded in expedience, rather than science.”